Background & Aims
Lumbar spine surgery is associated with high postoperative pain scores and analgesic use[1]. A multimodal analgesic regimen and locoregional anesthesia techniques are advised in multiple enhanced recovery after surgery (ERAS) programs[2]. A potential locoregional technique is the erector spinae plane block (ESPB), for which decent quality evidence exists in patients undergoing breast cancer surgery and video-assisted thoracoscopy in lowering postoperative pain scores and opioid use[3,4]. For lumbar spine surgery, evidence is increasing on the positive analgesic effect of ESPB. A recent systematic review included 19 trials (n=1.561 patients), of which seven were blinded, and ten were placebo-controlled[5]. The current trial aimed to contribute to the scientific evidence by using a larger, double-blinded, placebo-controlled design. The primary objective was to evaluate the additional analgesic effect of bilateral ESPB on early postoperative pain after lumbar spinal fusion surgery.
Methods
A prospective, single-center, randomized, double-blinded, placebo-controlled trial was conducted. Patients undergoing elective lumbar spine surgery with a dorsal surgical approach comprising 1-4 levels of fusion were recruited. Patients were aged ? 18 years. Exclusion criteria were BMI of ?40kg/m², ASA score >3, contra-indication to protocol medication, history of drug or alcohol abuse, inability to speak the Dutch language. The ESPB was placed at the end of surgery bilaterally on Th12 level with 30cc ropivacaine 0.375mg/mL or placebo, depending on randomization allocation. The ESPB was added to a standardized multimodal analgesic regimen. Primary outcome was difference in numeric rating scale (NRS) 1 hour after emergence from anesthesia between the groups. Secondary outcomes were NRS on day 1, 3 and 30; 12-hour opioid use (mg MEQ); time until opioid use; and quality of recovery (QoR15-NL on day 1 and 3). Baseline analysis and independent Student’s t-test were performed (?=0.05).
Results
76 patients (52.7% women, aged 60.5 (SD 10.5)) were included. 38 patients received the intervention and 36 patients placebo. No significant difference in NRS was found 1 hour after emergence from anesthesia (mean 3.82 [intervention]vs 4.19 [placebo], p-value 0.093). On postoperative day 1, 3 and 30, no significant differences in pain scores were found. The total opioid use in the first 12 hours postoperatively was 17.1mg in the intervention and 14.7mg in the placebo group (p-value 0.064). Time until opioid use was significantly extended (280 [intervention] vs 120 minutes [placebo], p-value 0.023). The QoR15-NL on postoperative day 1 and 3 were not significantly different (90 [intervention] vs 102 [placebo] on day 1; 108 vs 112 on day 3).
Conclusions
Little added value was found of the ESPB in elective lumbar spinal fusion surgery with a dorsal approach in terms of lowering postoperative pain or opioid consumption. Time until first opioid use was significantly extended in the intervention group. The study results are inconsistent with previously conducted randomized controlled trials[5,6]. Limitations of this study are the possibility of an added analgesic effect of normal saline (placebo) compared to no ESPB at all. Furthermore, this was a single-center study so generalizability of the study is somewhat limited. Strengths of the current trial are the standardization of the multimodal analgesic regimen, blinding of all caregivers and researchers, and the addition of a placebo, which limit the risk of bias of the results. Furthermore, this study adds to the scarce evidence on the added value of the ESPB in instrumented spinal fusion surgery.
References
1 Gerbershagen HJ, Aduckathil S, van Wijck AJM, et al. Pain Intensity on the First Day after Surgery. Anesthesiology. 2013;118:934–44.
2 Alboog A, Bae S, Chui J. Anesthetic management of complex spine surgery in adult patients: A review based on outcome evidence. Curr Opin Anaesthesiol. 2019;32:600–8.
3 Huang W, Wang W, Xie W, et al. Erector spinae plane block for postoperative analgesia in breast and thoracic surgery: A systematic review and meta-analysis. J Clin Anesth. 2020;66:109900.
4 Forero M, Adhikary SD, Lopez H, et al. The erector spinae plane block a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41:621–7.
5 Liu H, Zhu J, Wen J, et al. Ultrasound-guided erector spinae plane block for postoperative short-term outcomes in lumbar spine surgery: A meta-analysis and systematic review. Medicine (United States). 2023;102:E32981.
6 Ma J, Bi Y, Zhang Y, et al. Erector spinae plane block for postoperative analgesia in spine surgery: a systematic review and meta-analysis. European Spine Journal. 2021;34:487–500.
7 European Medicines Agency (EMA). Guideline Good Clinical Practice E6(R2). Committee for Human Medicinal Products. 2018;6:1–68.
Presenting Author
Ilse H. van de Wijgert
Poster Authors
Ilse van de Wijgert
MD
Sint Maartenskliniek
Lead Author
Kris Vissers
MD
Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center
Lead Author
Rianne van Boekel
Radboud University
Lead Author
Maaike G.E. Fenten MD PhD
Sint Maartenskliniek
Lead Author
Akkie Rood MD PhD
Sint Maartenskliniek
Lead Author
Miranda L. van Hooff
PhD
Department of Research, Sint Maartenskliniek, the Netherlands
Lead Author
Topics
- Treatment/Management: Interventional Therapies – Injections/Blocks